- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.00 / $398.00 / $398.00
| Professional | | $398.00 | $398.00 | $398.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.23 / $334.39 / $531.32
| Professional | | $284.23 | $334.39 | $531.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.48 / $1,260.73 / $3,749.33
| Facility | | $450.48 | $1,260.73 | $3,749.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.00 / $600.00 / $600.00
| Professional | | $600.00 | $600.00 | $600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $471.71 / $1,260.73 / $3,749.33
| Facility | | $471.71 | $1,260.73 | $3,749.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.00 / $600.00 / $600.00
| Professional | | $600.00 | $600.00 | $600.00 |